Managing Chronic Pain

Pain affects millions of people with diabetes. For most of these people, the pain is chronic, defined as pain persisting for more than six months, experienced almost every day, and of moderate to severe intensity, or that significantly interferes with daily activities. In some cases, a person’s pain is clearly related to complications of diabetes; in other cases, it is not. Regardless of the cause, however, studies show that chronic pain makes diabetes self-management much more difficult and often leads to higher blood glucose levels.

Surveys of people with diabetes report rates of chronic pain anywhere from 20% to over 60% – much higher than rates in the general population. The types of pain most often reported by people with diabetes include back pain and neuropathy pain in the feet or hands. (Peripheral neuropathy, or nerve damage in the feet and hands, is a common complication of diabetes.) Headaches and other pain sites are also frequently reported. Many people with diabetes also have arthritis, fibromyalgia (an arthritis-related illness that causes widespread muscle and joint pain and fatigue), or other painful conditions.

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Pain has been shown to interfere with self-management activities, sleep, physical functioning, work, family relationships, mood, and quality of life. To make matters worse, pain is often invisible to others, so family members, coworkers, and health-care professionals often have no idea what a person in pain is going through. Many people feel that their physicians don’t understand and tell them they “just have to live with it.”

Why is there so much pain, and what can be done about it?

Acute versus chronic pain

When speaking of pain, it’s important to understand the difference between acute and chronic pain. Acute pain is what a person feels from an injury like a burn or a medical problem like an earache. It’s your body’s natural reaction to injury. It tells you “Stop what you’re doing! Rest the part that hurts! Get some help!”

Acute pain is a lifesaver. Without it, we would have to watch out all the time to keep from injuring or killing ourselves accidentally. This is why people with diabetes are advised to check their feet visually or manually every day: If a person has peripheral neuropathy, particularly if it causes numbness in his feet, the acute pain nerves in his feet may not be working, and if they aren’t, they can’t warn him about injuries or other, normally painful foot problems.

Chronic pain is different from acute pain. It may have started with an injury, but it doesn’t necessarily reflect any injury going on at the moment. Sometimes there is ongoing inflammation or irritation, and sometimes not, but in chronic pain, the nervous system amplifies pain signals or misinterprets sensations as being much worse than they are.

According to Christine Sullivan, founder of Real Help for Chronic Pain, an online pain management program, “Chronic pain is almost never merely a physical thing. We can see from brain mapping that chronic pain uses very different nerve paths from acute pain. In fact, the brain maps of chronic pain look just like the brain maps of intense emotions like anger, or sadness, or fear.”

Like all sensations, pain is created by the brain from all kinds of input. The actual signals from nerve endings are part of the input. But those signals get blended with other sense signals and with thoughts, feelings, and memories. Then the brain organizes all this data and tries to make sense of it.

Neurologist V. S. Ramachandran, author of Phantoms in the Brain, says, “There is no direct hotline from pain receptors to ‘pain centers’ in the brain. [Instead,] there is much interaction between different brain centers, like those concerned with vision and touch.”

What this means is the exact opposite of saying that pain is “all in your head.” It means that pain is a summary of all the data that come into your brain from your whole body, your environment, your relationships, feelings, and beliefs. If the summary says, “Things are not well,” you will likely feel pain. Chronic pain is a whole body—mind experience. It always has a physical component, and it always has an emotional component, and there may be other factors as well.

What causes chronic pain?

Chronic pain can reflect injury that hasn’t completely healed. More often, it is caused by nerves that have become oversensitive or by a brain that is misreading the signals it receives. If acute pain goes on too long, nerves and brain can tire of the constant signals and just decide the injury is permanent. That’s why it’s important to treat acute pain seriously. For example, if you injure your foot or your back and don’t treat it promptly – with adequate rest, other first-aid measures, and seeing a doctor if the pain is severe or persists – mild pain can become severe, and acute pain can become chronic.

A good way to understand the many causes of chronic pain is by considering phantom limb pain. When people lose an arm or leg in an accident or surgery, about half of them will still feel that the limb is there. About half of those people develop serious pain in the phantom limb. Obviously, this isn’t due to physical injury going on in the moment. It’s a misunderstanding by the brain of the signals it is getting and not getting. The brain figures the signals add up to something seriously wrong, so it sends out an urgent pain message.

The same thing applies to the chronic back and leg pain so many people have. There may be a few pain signals coming up from tired muscles or joints toward the brain. Those signals go through nerve centers called “pain gates.” Those “gates” are where the signals are mixed with other sense data, feelings, and body states such as tension. In people with chronic pain, the gates amplify the signals over and over until the pain is severe. They do this because the brain thinks the person needs to be warned away from a real threat, such as taking a hand out of the fire so it doesn’t burn.

Anything that makes nerves more sensitive can increase pain. Feelings of stress, fear, helplessness, or anger can increase pain sensitivity. Trauma – such as a physical injury or psychological or sexual abuse – often leads to chronic pain later on. In a study of people with traumatic injuries conducted by researchers at the University of Washington in Seattle, nearly 63% had severe pain one year later. It may be that trauma causes nerves to become oversensitive as a way of trying to prevent further injury. This may be why military veterans have the highest rates of chronic pain.

Chronic pain creates several vicious cycles. For one, people tend to tense their muscles in response to pain, which often makes the pain worse. Pain also leads people to stop moving, which leads to increasing stiffness and more pain. Pain can interfere with sleep, and restless nights can increase pain. Pain also can contribute to depression and painful emotions such as anger, grief, fear, and frustration, which in turn contribute to pain.

Treating pain

Since chronic pain has so many contributing causes – physical, mental, and emotional – there are many ways to break into the pain cycle, reduce pain levels, and gain comfort. There may not be a cure for chronic pain, but a person can gain some control over his pain. Feeling more in control, even a little bit, can help people relax, try new things, and gain even more control. In this way, even severe chronic pain can be managed, and the person with pain can gain better health in the process.

There are five main approaches for treating and self-managing pain: These include physical, neurological, mental, spiritual, and “alternative” approaches.

Physical approaches

Physical treatments for chronic pain can include applying heat or cold to the part that hurts, massage, exercise, and rest. Sensations of heat, cold, and touch travel on the same nerves as pain sensations, but they travel faster. A sensation of gentle touch, heat, or cold will therefore beat a pain signal to the next pain gate and block the pain from getting through. Certain substances including capsaicin (chili pepper extract) provide a sensation of heat when rubbed on the skin that may keep a pain gate blocked for hours.

Exercise is often one of the best treatments for pain. Responding to an entry on pain in the Diabetes Self-Management Blog, a Canadian man with Type 2 diabetes reported, “I have cured my back pain completely since starting weight-lifting exercises 18 months ago. I do horizontal and inclined bench presses. I started with 50 lbs and built to 150 lbs. The benches provide complete back support.”

Strengthening muscles eases pressure on the joints and tendons. It also gives you a greater sense of control, which really helps people deal with pain. Stretching to increase your flexibility can also be helpful for pain relief, when done as part of a regular exercise routine. Walking, sitting, and moving with good posture and balance can take pressure off tender muscles and nerves. You may want to consult a physical therapist to find exercises that are right for you.

Massage and other kinds of bodywork can greatly relieve pain. Bodywork can include acupressure, shiatsu, and various other types of therapeutic touching or manipulation of the body.

Certain drugs may also help to control pain. These include anti-inflammatory medicines such as ibuprofen, aspirin, naproxen, indomethacin, and many others. While some of these are sold over the counter, they can have side effects, most notably gastrointestinal bleeding. A newer anti-inflammatory, celecoxib (Celebrex), may have fewer gastrointestinal side effects.

Neurological approaches

Many drugs can help calm down overactive pain nerves. These include antiseizure medicines such as gabapentin (brand name Neurontin) and pregabalin (Lyrica). Since seizures are the most obvious case of oversensitive nerves, it makes sense that seizure drugs might help chronic pain. Lyrica seems to have fewer side effects than Neurontin and another drug, Topamax, which often cause mental fogginess.

Electrical stimulation can sometimes block pain signals from traveling up the nerves. The most commonly used system is called TENS, which stands for transcutaneous electrical nerve stimulation. TENS works by sending electrical pulses across the surface of the skin into the nerves. The stimulating pulses help prevent pain signals from reaching the brain. They also help stimulate your body to produce higher levels of its own natural painkillers, called endorphins.

Relaxation exercises, meditation, and prayer also help nerves calm down. So can doing relaxing things like spending time in nature, playing with a pet, or engaging in a hobby like knitting or painting.

Chronically high blood glucose levels are known to damage nerves, so keeping blood glucose levels close to the normal, nondiabetic range can greatly reduce neuropathic pain. (Sometimes, however, if nerve damage has caused numbness in the feet, legs, hands, or arms, improving blood glucose control can cause pain in these areas as the nerves start to heal and regain function. The pain is usually temporary.)

Mental approaches

Your thoughts can affect pain severity. In wartime, soldiers’ wounds often are less painful than the same wounds would be in a civilian. Why? Because the wounds signify that the wounded soldier will soon be going home, but the civilian’s injury is a source of fear and anxiety. This is known as the “Anzio effect” after the World War II battle that took place near Anzio, Italy, where it was first noted.

When pain is a source of fear, anger, or grief, it usually hurts more. Cancer patients may experience worse pain, because they fear it means their disease is worsening or that they may be dying. Because your thoughts about your pain have a major effect on how bad it feels, it can help to change your thoughts. For example, you might try changing a negative thought such as, “This pain keeps me from doing everything I like,” to a more realistic, positive one such as, “This pain makes it harder to do things, but I can sometimes find different ways to do them.” Doing this can actually turn down your pain level.

Distraction is one of the best short-term mental approaches. The Chronic Disease Self-Management Program developed by Stanford University recommends mental exercises like counting backward by sevens, imagery such as imagining a beach scene, or playing a game. Several studies have found playing video games to be a terrific pain reliever.

One participant in an online discussion on the Diabetes Self-Management Blog wrote, “I noticed that when I was doing something like reading an interesting book, or walking and talking with a friend, I was not consciously feeling pain.” Another wrote, “I keep my mind busy with genealogy [family history] during the day. I play sudoku and crosswords at night until I can fall asleep.”

Certain drugs that affect the brain can help to control chronic pain. Antidepressants in the class of drugs known as selective serotonin reuptake inhibitors (SSRIs), which including duloxetine (Cymbalta), are often prescribed for pain. So are tricyclic antidepressants (TCAs) such as amitriptyline (Elavil). SSRIs often boost energy, while TCAs can make you sleepy. According to the Harvard Medical School Web site, “Some physicians prescribe an SSRI during the day and amitriptyline at bedtime for pain patients.”

Narcotic medicines, which include opiates such as morphine and synthetics such as oxycodone, are sometimes given for pain. Narcotics dampen all senses, not just pain. Because of side effects including sleepiness, constipation, and addiction, they are less often used for chronic pain than they used to be. But they are still very helpful for some people, and most chronic pain specialists will prescribe them.

Spiritual approaches

Pain specialist Karen Burt, M.D., director of Integrative Medicine at Contra Costa Regional Health Center in California, says that spiritual approaches help many people with chronic pain. “With chronic pain,” she says, “one needs to connect or return to all positive aspects of one’s being and one’s life. So if puppies and kids and nature and flowers and hot baths and your sister bring you pleasure and comfort, by all means, keep them in your life. By the same token, everyone has internal sources of positivity: one’s faith, one’s awe and appreciation of nature or life itself, and qualities like strength, courage, wisdom, hope, and inspiration.”

Dr. Burt talks of “developing a witness within,” a part of you that sees what your mind and body are going through, but does not identify as the one who is suffering. This practice helps to “open up a bigger sense of who you are” [so] you see that pain is only part of your experience.

Citing the work of Maggie Phillips, Ph.D., author of the book Reversing Chronic Pain, Dr. Burt suggests “going back and forth in your consciousness, from noticing the pain to noticing other neutral or positive feelings in other parts of your body. You may even notice elements of joy and pleasure – even while the pain is still there.”

Alternative therapies

Herbs and oils have long been used to relieve pain. Though there haven’t been many scientific studies of their use, some small studies have shown significant benefit from rubbing on certain essential oils (concentrated plant extracts), including lavender, peppermint, cinnamon, rose, clove, rosemary, ginger, and others. It was not clear whether it was the oils or the touch that made the difference.

Many herbal remedies have been used to reduce inflammation and pain. Writing in the online publication U.S. Pharmacist, Antoine Al-Achi, Ph.D., an Associate Professor of Pharmaceutics at the Campbell University School of Pharmacy in North Carolina, reported that bromelain (pineapple enzyme), curcumin (an antioxidant found in turmeric), echinacea, chamomile, ginger, and arnica have shown anti-inflammatory effects. Preparations of these plant-based supplements are widely available at health-food stores. If you would like to try one or more of these supplements, speak to your doctor first about possible side effects and drug interactions.

Whole body—mind treatments

Since chronic pain is a whole body—mind experience, your total physical and mental health has a lot to do with your pain. In addition to improving your blood glucose control, you might consider doing the following:

Lose some weight.Losing some excess weight can take the pressure off your back, hips, knees, and feet, possibly reducing pain in these areas.

Watch what you eat. Different foods may well make your pain worse or better. You may want to keep a log of what you eat and how it affects your pain. (Click here for a log that can help you keep track of your diet and various other factors that may affect pain.)

Pace yourself. People tend to push themselves until pain or fatigue makes them stop. They then rest for the shortest possible time, then get back to work until pain stops them again. You can prevent this cycle by pacing yourself: Figure out how much you can do without pain, and stop before you reach that point. Rest up, then start again. You’ll get more done with less pain.

Laugh. Several studies show laughter is among the best medicines for pain. In Japanese studies of arthritis, people who watched a humorous show reduced their pain by more than 50% for as long as 12 hours. You can watch funny videos or read humorous writing, watch kids or puppies play, or do whatever it takes to make you laugh. You can also laugh for no reason at all. The effect seems to be the same.

Engage in sex.Sex is a good pain reliever, and orgasm is more powerful than almost any drug in relieving pain. Rutgers University professor and sex researcher Beverly Whipple, Ph.D., found that when women had orgasms, their pain “thresholds” went up by more than 108%. In other words, things that usually hurt them no longer had an effect. She believes men have similar responses, though she’s only studied women. The pain-reducing effect seems to last for hours.

Sleep. A good night’s sleep is great medicine for pain. There are many medical and behavioral approaches to help you sleep. See “Finding Help for Chronic Pain” for some written resources on sleep.

Getting help

If you are suffering with chronic pain, get some help! Although the help you need may not be around the corner, it is available.

If possible, find a pain center that your insurance will pay for. Pain centers should combine physical, mental, and medical approaches and provide support from both professionals and other people living with pain. Some have brief residential programs followed by outpatient services. Most are entirely outpatient, and appointments are scheduled for several times a week at first, until a person’s pain is controlled adequately. A pain center may provide physical therapy, counseling, medication, self-management training, and more.

With or without a pain center, it’s best to find a pain specialist you feel you can trust. According to Dr. Burt, “A good pain specialist is open to different approaches – whatever works for you. You don’t want someone who is pushing one particular thing. Expect that a variety of healing modalities will be needed.”

She says a good pain doctor has a sense of humor, listens to you, gives you hope, and is open to trying new things. “A pain specialist should care about all aspects of your life. She knows that a lot of the responsibility for pain treatment is yours, and empowers you to take it.”

An important part of pain treatment is the support of other people. Being with other people who live with pain and understand what you’re going through makes you feel better and gives you courage. The support of others makes you stronger. It increases your confidence to try new things.

If you can’t find a chronic pain program, perhaps you can find a chronic pain support group. Or perhaps you can start your own or join an online group. Your doctor may be able to connect you to other patients with pain issues. Chronic pain specialists often say, “The group is the medicine.” So join one!

You may not be able to completely eliminate pain. But you can eliminate suffering. You can make pain a smaller and smaller part of your life and become healthier in the process.

David Spero is author of Diabetes: Sugar-coated Crisis, (New Society, 2006) and The Art of Getting Well: Maximizing Health When You Have a Chronic Illness (Hunter House, 2002). He writes for Diabetes Self-Management and Arthritis Self-Management magazines regularly and blogs at www.diabetesselfmanagement.com/blog. See more of David’s work at www.davidsperorn.com.

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